Provider Demographics
NPI:1881717148
Name:BELUSHI, SANDRA DAVENPORT
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:DAVENPORT
Last Name:BELUSHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1051
Mailing Address - Country:US
Mailing Address - Phone:708-712-9644
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:SUITE 45
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4405
Practice Address - Country:US
Practice Address - Phone:708-712-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical